Application and Research Progress of Ultrasound-Guided Brachial Plexus Block Through Costoclavicular Space Approach in Upper Limb Surgery.

Objective: Exploring newer approaches to brachial plexus block is crucial for improving surgical outcomes and patient comfort. This study aims to review the application and research progress of ultrasound-guided brachial plexus block via the costoclavicular space approach in upper limb surgery. Methods: This study provides a comprehensive review of existing literature, studies, and clinical cases related to the costoclavicular approach. The advantages and disadvantages of conventional approaches for brachial plexus block, including the intermuscular groove method, supraclavicular method, and axillary approach, are discussed. The anatomical characteristics of the costoclavicular space are examined, and the methods of brachial plexus nerve block using ultrasound-guided costoclavicular space approach are described. It holds great promise for enhancing patient care and increasing the overall success rate of surgical procedures. Results: The costoclavicular space approach for brachial plexus block offers several advantages, including stable anatomical structure, low nerve variation rate, and clear visualization of each nerve bundle under ultrasound imaging. Compared to traditional approaches, ultrasound-guided brachial plexus block via the costoclavicular space approach has a high success rate, rapid onset of anesthesia, and high safety. Conclusion: Ultrasound-guided brachial plexus block via the costoclavicular space approach is effective and safe in upper limb surgery. It provides good anesthesia and postoperative analgesia, making it a valuable technique for various upper limb surgeries. The potential clinical significance of our findings lies in the possibility that ultrasound-guided costoclavicular space approach, with its enhanced precision and patient outcomes, could play a pivotal role in improving upper limb surgical procedures.

Efficacy of Nalbuphine as a Local Anesthetic Adjuvant for Brachial Plexus Block: A Systematic Review and Meta-analysis.

BACKGROUND: Nalbuphine has been increasingly used as a local anesthetic adjuvant to extend the duration of analgesia in brachial plexus block (BPB). OBJECTIVES: To systematically and firstly evaluate the available evidence on the efficacy of nalbuphine as an adjuvant to local anesthetics in BPB. STUDY DESIGN: Systematic review and meta-analysis. METHODS: Cochrane Central Register of Controlled Clinical Trials, Cochrane Database of Systematic Reviews, Medline, Embase, Scopus, Web of Science, EBSCO, PubMed, and additional databases were searched. Randomized controlled trials comparing combination of perineural nalbuphine with local anesthetics to local anesthetics alone in BPB for upper extremity surgical procedures were eligible for inclusion. RESULTS: Nineteen randomized controlled trials involving 1,355 patients met the inclusion criteria. Perineural use of nalbuphine prolonged the duration of analgesia in BPB (mean difference [MD], 162.5; 95% confidence interval [CI], 119.0 to 205.9; P < 0.00001; very low quality of evidence). The duration of sensory block was also extended (MD, 141.6; 95% CI, 100.3 to 182.9; P < 0.00001; very low quality of evidence). Furthermore, nalbuphine shortened the onset time of sensory block (MD, -2.6; 95% CI, -3.6 to -1.5; P < 0.00001; very low quality of evidence). There were no significant differences in side effect-related outcomes, including nausea (risk radio [RR], 1.56; 95% CI, 0.82 to 2.59; P = 0.17; moderate quality of evidence) and vomiting (RR, 1.41; 95%  CI, 0.66 to 3.02; P = 0.38; moderate quality of evidence). LIMITATIONS: The study was limited by substantial heterogeneity, a relatively small sample size and difference-in-differences in how outcomes of interest were described and assessed. CONCLUSIONS: Perineural use of nalbuphine in BPB is an effective strategy for analgesia in adult patients undergoing upper extremity surgery.

Analysis of Anesthesia Effect of Dexmedetomidine in Clinical Operation of Replantation of Severed Finger.

Brachial plexus block commonly used in finger replantation has the advantages of simple operation, small side effects, and stable circulation, but it has inherent problems such as imperfect block range, slow onset of anesthesia, and short maintenance time of anesthesia. In order to explore the reliable clinical anesthesia effect, this paper uses experimental investigation methods to study the effect of dexmedetomidine in clinical surgery of replantation of severed fingers. Moreover, this paper uses comparative test methods, uses statistical methods to process test data, and uses intuitive methods to display test results. Finally, this paper verifies the reliability of dexmedetomidine in replantation of severed finger through comparative analysis and verifies that the anesthesia method proposed in this paper has certain user satisfaction through parameter survey.

Local anesthetic volume in ultrasound-guided interscalene block and opioid consumption during shoulder arthroscopic surgery: A retrospective comparative study.

ABSTRACT: Interscalene block (ISB) is commonly performed for regional anesthesia in shoulder surgery. Ultrasound-guided ISB enables visualization of the local anesthetic spread and a reduction in local anesthetic volume. However, little is known about the appropriate local anesthetic dose for surgical anesthesia without sedation or general anesthesia. The purpose of our study was to evaluate the appropriate local anesthetic volume by comparing intraoperative analgesics and hemodynamic changes in ISB in arthroscopic shoulder surgery.Overall, 1007 patients were divided into groups 1, 2, and 3 according to the following volume of local anesthetics: 10-19, 20-29, and 30-40 mL, respectively. The use of intraoperative analgesics and sedatives, and the reduction in intraoperative maximum blood pressure and heart rate were compared through retrospective analysis.Fentanyl was used in 55.6% of patients in group 1, which was significantly higher than in those groups 2 and 3 (22.3% and 30.7%, respectively); furthermore, it was also higher than those in groups 2 and 3 in dose-specific comparisons (P < .05). The percent of the maximum reduction in intraoperative systolic blood pressure and heart rate in group 3 was significantly higher than those in groups 1 and 2. Ephedrine administration was lower in group 2 than that in other groups (P < .05). The incidence of hypotensive bradycardic events was lowest (9.1%) at the local anesthetic volume of 24 mL as revealed by the quadratic regression analysis (R2 = 0.313, P = .003).Decreasing the local anesthetic volume to less than 20 mL for ultrasound-guided ISB as the sole anesthesia increases the opioid consumption during shoulder arthroscopic surgery. Local anesthetics >30 mL or increased opioid consumption with <20 mL of local anesthetics could increase the risk of cardiovascular instability intraoperatively. Our findings indicate that 24 mL of local anesthetic could be used to lower the incidence of hypotensive bradycardic events.

Single- versus double-injection costoclavicular block: a randomized comparison.

BACKGROUND: The costoclavicular approach targets the brachial plexus in the proximal infraclavicular fossa, where the lateral, medial, and posterior cords are tightly bundled together. This randomized trial compared single- and double-injection ultrasound-guided costoclavicular blocks. We selected onset time as the primary outcome and hypothesized that, compared with its single-injection counterpart, the double-injection technique would result in a swifter onset. METHODS: Ninety patients undergoing upper limb surgery (at or below the elbow joint) were randomly allocated to receive a single- (n=45) or double-injection (n=45) ultrasound-guided costoclavicular block. The local anesthetic agent (35 mL of lidocaine 1%-bupivacaine 0.25%with epinephrine 5 µg/mL and 2 mg of preservative-free dexamethasone) was identical in all subjects. In the single-injection group, the entire volume of local anesthetic was injected between the three cords of the brachial plexus. In the double-injection group, the first half of the volume was administered in this location; the second half was deposited between the medial cord and the subclavian artery. After the performance of the block, a blinded observer recorded the onset time (defined as the time required to achieve a minimal sensorimotor composite score of 14 out of 16 points), success rate (surgical anesthesia) and block-related pain scores. Performance time and the number of needle passes were also recorded during the performance of the block. The total anesthesia-related time was defined as the sum of the performance and onset times. RESULTS: Compared with its single-injection counterpart, the double-injection technique displayed shorter onset time (16.6 (6.4) vs 23.4 (6.9) min; p<0.001; 95% CI for difference 3.9 to 9.7) and total anesthesia-related time (22.5 (6.7) vs 28.9 (7.6) min; p<0.001). No intergroup differences were found in terms of success and technical execution (ie, performance time/procedural pain). The double-injection group required more needle passes than the single-injection group (2 (1-4) vs 1 (1-3); p<0.001). CONCLUSION: Compared with its single-injection counterpart, double-injection costoclavicular block results in shorter onset and total anesthesia-related times. Further investigation is required to determine if a triple-injection technique (with targeted local anesthetic injection around each cord of the brachial plexus) could further decrease the onset time. TRIAL REGISTRATION NUMBER: NCT03595514.

Ultrasound Guidance Enhances the Efficiency of Brachial Plexus Block and Ameliorates the Vascular Injury Compared with Nerve Stimulator Guidance in Hand Surgery Patients.

Background: Nerve stimulation guidance and ultrasound guidance are two major methods that have been widely accepted and applied in axillary brachial plexus block. However, the differences between the effects of these two types of guidance still need to be further elucidated for clinical usage. Materials and Methods: Overall, 208 patients undergoing elective upper limb surgeries and receiving axillary brachial plexus block were recruited in our study. The patients were randomly assigned to receive either ultrasound guidance (group U, n = 112) or nerve stimulation (group N, n = 96). Pinprick test was performed for assessing the sensory blockades. The pain was evaluated by visual analog scale (VAS). Reactive oxygen species (ROS) levels were measured by dichloro-dihydro-fluorescein diacetate staining and serum levels of nitric oxide (NO), nitric oxide synthases (NOS), tumor necrosis factor (TNF)-α, and monocyte chemoattractant protein 1 (MCP1) were evaluated by ELISA. Results: Ultrasound guidance significantly enhanced the quality of the sensory blockade and reduced the VAS scores when compared with the nerve stimulator guidance. In addition, the production of ROS, NO, NOS, TNF-α, and MCP-1 were significantly alleviated by ultrasound guidance. Conclusion: Ultrasound-guided brachial plexus block relieves pain during operation, provides higher success rates in the nerve block, causes less vascular damage and results in lower levels of inflammatory cytokines secretion when compared with neurostimulator-directed brachial plexus blockage.

COMPARISON OF PLEXUS BRACHIAL BLOCKADE EFFECT BY SUPRACLAVICULAR AND AXILLARY APPROACH - OUR EXPERIENCE.

INTRODUCTION: Brachialis plexus block is a frequently used method of regional anesthesia that can be performed in several ways and locations. It has been successfully performed to provide good anesthesia and analgesia lasting several hours for operative procedures on hands. It can be performed by paresthesia technique or by ultrasound that has almost pushed out the old conventional technique since it allows the visualization of the blockade performance. TARGET: In the paper we use our sample to try to determine which of the two locations of the blockageis more favorable for the patient, and which one gives a higher percentage of success or a better sensory blockade. METHOD: This is a retrospective study and includes 40 patients of both sexes that were operated on at the Clinic for Traumatology and the Clinic for Plastic Surgery of the University Clinical Center in Sarajevo in the period from 30 August 1993 to 30 August 1994. Patients were divided into two groups. Group I were patients who had an axillary approach to plexus brachialis (n-21) ASA I-II. Group II were patients who had supraclavicular access to plexus brachialis (n-19) ASA I-II. All patients received 0.5 ml / kg Bupivacaine 0.5%. In the study, we analyzed sex, age, duration of blockade and complications. Analgesia and motor block were evaluated 20 minutes after the local anesthetic injection. The complete block is defined as analgesia in all dermatomes (C5-Th1) 20 minutes after injection. THE RESULTS: Group I had 20 male and 1 female patients while group II had 17 male and 2 female patients. The supraclavicular block enabled complete blockade in 18 patients (95.23%), and the axillary approach had a successful blockade in 17 patients (80.95%). In both groups the corresponding motor block was similar. The start of the engine block was similar in both groups. There were no significant complications in either group. CONCLUSION: Regarding clinical efficacy, both brachial plexus blocking approaches provided a good motor block, anesthesia and analgesia for the forearm or hand surgery. Supraclavicular approach proved to be more favorable.

Contemporary Approaches to Postoperative Pain Management.

LEARNING OBJECTIVES: After reading this article, the participant should be able to: 1. Describe the fundamental concepts of multimodal analgesia techniques and how they target pain pathophysiology. 2. Effectively educate patients on postoperative pain and safe opioid use. 3. Develop and implement a multimodal postoperative analgesia regimen. SUMMARY: For many years, opioids were the cornerstone of postoperative pain control, contributing to what has become a significant public health concern. This article discusses contemporary approaches to multimodal, opioid-sparing postoperative pain management in the plastic surgical patient.

Interscalene brachial plexus catheter versus single-shot interscalene block with periarticular local infiltration analgesia for shoulder arthroplasty.

BACKGROUND: Interscalene brachial plexus block is a commonly employed regional anesthetic technique for total shoulder arthroplasty, and a continuous catheter is often placed to extend the analgesic benefit of the block. As periarticular local infiltration analgesia (LIA) for total joint arthroplasty is a re-emerging trend, we evaluated the analgesic efficacy of continuous interscalene block (CISB) compared to single-shot interscalene block (SSISB) with LIA. METHODS: We conducted a retrospective review of 130 consecutive patients treated by one surgeon in a single institution, with 12 patients excluded for history of chronic opioid tolerance and two for incomplete data. The SSISB with LIA treatment group (N.=53) was compared to a control group who received CISB (N.=63). Primary end points were a difference in pain score (0-10 numeric rating scale) and opioid requirements as oral morphine equivalents (OMEs) on postoperative days (PODs) 0 and 1. Secondary end points included nausea and vomiting, length of hospital stay, block failure rate, adverse events due to block, and 30-day readmission. RESULTS: When compared to SSISB with LIA, patients who received CISB exhibited decreased opioid requirements in OMEs on POD 0 (11.9 mg vs. 28.7 mg, P<0.01) and POD 1 (24.0 mg vs. 50.3 mg, P<0.01). There was no significant difference in pain on POD 0, but a statistically significant decrease in average pain scores with CISB on POD 1 (2.3 vs. 4.3, P<0.01). CONCLUSIONS: SSISB with LIA may provide clinically similar postoperative analgesia compared to CISB, but with escalating doses of opioid requirements.

Brachial plexus block of the posterior and the lateral cord using ropivacaine 7.5 mg/mL.

BACKGROUND: We recently showed that the novel combination of a superficial cervical plexus block, a suprascapular nerve block, and the lateral sagittal infraclavicular brachial plexus block (LSIB) provides an alternative anaesthetic method for arthroscopic shoulder surgery. In this study, we hypothesised that the LSIB dose for this shoulder block could be significantly reduced by injecting only towards the shoulder relevant posterior and lateral cords. Our aim was to determine the minimum effective volume in 50% of the patients (MEV50 ) and to estimate the MEV95, when using ropivacaine 7.5 mg/mL to block these cords. METHODS: Twenty-three adult patients scheduled for hand surgery participated in the study. Considering the artery as a clock face with 12 o'clock ventral, the designated volume was injected immediately outside the arterial wall and between 8 and 9 o´clock. The in-plane technique was used. Block success was assessed 30 minutes after withdrawal of the needle. Successful posterior cord block was defined as anaesthesia or analgesia of the axillary nerve. Successful lateral cord block was defined as either anaesthesia or analgesia, or >50% motor block of the musculocutaneous nerve. MEV50 was determined by the staircase up-and-down method. Logistic regression and probit transformation were applied to estimate MEV95 . RESULTS: MEV50 and MEV95 were 7.8 mL [95% confidence interval (CI), 7.3-8.4] and 9.0 mL (95% CI, 7.8-10.3), respectively. CONCLUSION: For single-deposit infraclavicular posterior and lateral cord block, the MEV95 of ropivacaine 7.5 mg/mL was estimated to 9.0 mL.

EFFECTS OF CONVERSATIONAL HYPNOSIS ON RELATIVE PARASYMPATHETIC TONE AND PATIENT COMFORT DURING AXILLARY BRACHIAL PLEXUS BLOCKS FOR AMBULATORY UPPER LIMB SURGERY:A Quasiexperimental Pilot Study.

This two-center quasiexperimental pilot study was to determine the effect of conversational hypnosis on patient comfort and parasympathetic tone, which may represent a quantitative measure of hypnotic depth, during regional anesthesia. The patients received conversational hypnosis in one center and oral premedication in the other. The patients' subjective comfort (0-10 rating scale) and objective parasympathetic tone, as assessed by the Analgesia/Nociception Index (ANI), were measured before and after regional anesthesia. The parasympathetic tone and comfort scores evidenced a significantly greater increase in the hypnosis patients than in controls. These findings suggest that using conversational hypnosis during regional anesthesia may be followed by a subjective increase in patient comfort and an objective increase in parasympathetic tone, monitored by ANI.

Randomised controlled trial of analgesic effectiveness of three different techniques of single-shot interscalene brachial plexus block using 20 mL of 0.5% ropivacaine for shoulder arthroscopy.

BACKGROUND: Shoulder arthroscopic procedures impose a challenge to anaesthesiologists in terms of postoperative analgesia. Proper pain management after arthroscopic procedures improves patient satisfaction and facilitates early rehabilitation. METHODS: We performed a randomized, prospective clinical study to assess the influence of anthropometric parameters and IBPB technique on the quality of postoperative analgesia. A total of 106 randomly selected patients of ASA I-III status scheduled for elective shoulder arthroscopy. Reasons for exclusion were neurological deficit in the upper arm, allergies to amide-type local anesthetics, coagulopathy, and pregnancy.The patients received 20 mL of 0.5% ropivacaine for an ultrasound-guided interscalene brachial plexus block (IBPB) (group U), peripheral nerve stimulation (PNS)-confirmed IBPB (group N), or ultrasound-guided, PNS-confirmed IBPB (dual guidance; group NU). RESULTS: We observed that the three groups did not differ in mean time of sensory and motor block terminations. In individual cases in each group, sensory block lasted up to 890-990 minutes, providing satisfactory long lasting postoperative analgesia in patients receiving IBPB. We observed a negative correlation between body mass index and termination of motor block (P = 0.037, Pearson's correlation coefficient) and a positive correlation between age and termination of sensory block (P = 0.0314, Pearson's correlation coefficient) in group U compared to the other two groups. We found a positive correlation between male gender and termination of motor block (P = 0.0487, Pearson's correlation coefficient) in group N compared to the other two groups. CONCLUSION: In our study, patients received satisfactory analgesia in the postoperative period regardless of technique used, age, gender, or potentially uncommon anthropometry.

Electric Nerve Stimulation Does Not Correctly Predict Needle-Nerve Distance and Potential Local Anesthetic Spread for Interscalene Brachial Plexus Blockade.

This study evaluated electric nerve stimulation as a nerve location tool. After eliciting motor response in 43 patients undergoing shoulder surgery, the needle tip's position, distance from the closest nerve, and spread of saline were evaluated using ultrasound imaging. The needle's tip resided 1 to 4 mm from the closest nerve in 21, in direct contact with it in 7, and 6 to 18 mm away in 15 patients. In 21 patients, subsequent saline dissection did not reach the brachial plexus. Thus, the success rate of electric nerve stimulation for correct needle-nerve distance identification was 48.8%, with correct fluid spread reached in only 51.2% of patients.

Can we use lower volume of local anesthetic for infraclavicular brachial plexus nerve block under ultrasound guidance in children?

OBJECTIVES: To determine if the infraclavicular brachial plexus block can be applied with lower volume of local anesthetic. DESIGN: Randomised, double-blinded clinical trial. PATIENTS: 60 patients aged 5-15years with ASA I-II who underwent emergent or elective arm, forearm or hand operations were included in the study. INTERVENTIONS: Patients were divided into two groups randomly; standard volume local anesthetic administered group (Group S, n=30) and low volume anesthetic administered group (Group L, n=30). MEASUREMENT: Postoperative pain scores, sensory and motor block durations were noted. MAIN RESULTS: Pain scores (Wong-Baker Face Scale) were evaluated and the results were detected to be similar at all times (30min, 1, 2, 4, 8, 12, 24h). Durations of motor block were 168(±16) minutes and 268(±15) minutes in Group L and Group S respectively and the difference was statistically significant (p<0.001). Durations of sensory block were 385(±26) and 402(±39) in Group L and Group S respectively and no statistically significant difference was detected (p=0.064). CONCLUSION: Similar block success, postoperative sensory block durations and pain scores could be obtained during infraclavicular brachial plexus in pediatric patients with lower local anesthetic volumes.

Effect of Local Anesthetic Concentration (0.2% vs 0.1% Ropivacaine) on Pulmonary Function, and Analgesia After Ultrasound-Guided Interscalene Brachial Plexus Block: A Randomized Controlled Study.

OBJECTIVE: This study aims to assess diaphragmatic excursion and measure pulmonary functions as measures of the degree to which the phrenic nerve is blocked after ISB with two different concentrations of ropivacaine: 0.2% and 0.1%. DESIGN: Randomized, double-blinded study. SETTING AND PATIENTS: Ambulatory surgical facility. SUBJECTS: Fifty patients undergoing shoulder arthroscopy for rotator cuff repair. METHODS: Patients were randomized to receive ultrasound-guided ISB with 20 mL of either 0.2% or 0.1% ropivacaine. Diaphragmatic excursion was measured using M-mode ultrasound. Pulmonary functions were assessed by portable spirometer. Additional outcome data included oxygen saturation in post-anesthesia care unit (PACU), pain scores, quality of recovery scores (QOR), and opioid consumption over 72 hour period after surgery. RESULTS: Forced vital capacity (FVC) was significantly reduced 30 minutes after block placement and in PACU in the 0.2% group when compared with the 0.1% group (P = 0.04, P = 0.03, respectively). Forced expiratory volume (FEV1) was also significantly decreased in the 0.2% group in PACU when compared with the 0.1% group (P = 0.04). There were no significant differences in pain scores, length of stay, and total opioid consumption in PACU. Patients who received 0.2% ropivacaine had a longer block duration (18 vs 11.9 hours, P = 0.04) and used less opioid in the 72 hours after surgery (55 mg vs 102 mg codeine equivalents, P = 0.02), when they were compared to their counterparts who received 0.1% for their block. CONCLUSION: 0.1% ropivacaine may impair pulmonary function less than 0.2% ropivacaine. The clinical significance of these differences needs to be further studied.

[A study on diaphragm function after interscalene brachial plexus block using a fixed dose of ropivacaine with different concentrations].

OBJECTIVE: To compare the effect of interscalene brachial plexus block (ISBPB) on the incidence of diaphragmatic paralysis, respiratory function and post-operative pain control using same dosage of local anesthetics diluted into two different volume and concentrations. METHODS: Approved by the Peking University Third Hospital ethics committee, sixty patients undergoing elective arthroscopic shoulder surgery in Peking University Third Hospital from November 2013 to April 2014 were randomly allocated into two groups according to random number table method: before induction of general anesthesia, ultrasound-guided ISBPB was performed using 0.5% ropivacaine 10 ml (Group A) or 0.25% ropivacaine 20 ml (Group B). The incidence of diaphragmatic paralysis, respiratory function and reduction of pulse oxygen saturation at 30 min post-block were recorded and analyzed.Patients were interviewed at 4, 8 and 24 h after block for numerical rating pain score, rescue analgesics requirement and sleep quality. RESULTS: There were no statistically differences between group A and group B for the incidence of diaphragmatic paralysis at 30 min after block (67% vs 70%, χ(2)=0.077, P>0.05). The change of forced vital capacity ((78±16)% vs (80±18)%, t=0.435, P>0.05), the change of forced expiratory volume in 1 second ((85±16)% vs (78±22)%, t=1.472, P>0.05) and the reduction of pulse oxygen saturation (1(0-3)% vs 2(0-3)%, Z=-0.538, P>0.05) showed no significant differences between the two groups at 30 min after block.There were no statistically differences in terms of the numerical rating pain score, rescue analgesics requirement and sleep quality at 4, 8 and 24 h after block (all P>0.05). CONCLUSIONS: The use of 0.5% and 0.25% ropivacaine 50 mg for interscalene block provides similar effect on the incidence of diaphragmatic paralysis, changes in respiratory function and postoperative analgesia.

The efficacy of simultaneous bilateral axillary brachial plexus block under the guidance of neurostimulator or ultrasound: a prospective study.

PURPOSE: This study was designed to investigate the risk of local anesthetic toxicity and efficacy of simultaneous bilateral axillary brachial plexus block performed under the guidance of ultrasound or a neurostimulator. METHODS: One hundred and twenty patients who were anesthetized with bilateral axillary plexus block simultaneously between February 2012 and March 2014 were enrolled in the study. The patients were anesthetized under the guidance of a neurostimulator (group N, n = 60) or ultrasound (group U, n = 60). The block performance time, procedure-related pain, adverse events, total and free plasma concentrations of ropivacaine, and other data were recorded. The comparison was analyzed statistically. RESULTS: The block performance time, and onset of the sensory and motor block, of group N was longer than that of group U (p < 0.001). The procedure-related pain of group N was more serious than that of group U (p < 0.05). The patient satisfaction rate of group U was higher than that of group N (p < 0.05). The total plasma concentrations of ropivacaine in group N were comparable to those of group U, except for the value at 50 min after injection (p < 0.05). The free plasma concentrations of ropivacaine of group N at 5 min were significantly higher than that of group U (p < 0.001). No apparent serious adverse events were observed perioperatively in both groups. CONCLUSIONS: Simultaneous bilateral axillary brachial plexus block guided by neurostimulator or ultrasound in bilateral distal upper extremity surgery seems to have a low risk of local anesthetic toxicity and to be effective. The ultrasound-guided block is superior in terms of providing the same degree of anesthesia with shorter duration, less pain, and faster onset of sensory and motor blockades, which is important in clinical practice.

Postoperative Analgesia in a Prolonged Continuous Interscalene Block Versus Single-Shot Block in Outpatient Arthroscopic Rotator Cuff Repair: A Prospective Randomized Study.

PURPOSE: To compare the analgesic efficacy of 3-day continuous interscalene brachial plexus block versus a single-shot block for arthroscopic rotator cuff repair. METHODS: Eighty-five patients scheduled for arthroscopic rotator cuff repair were randomly assigned to either the single-shot group (SSG) or continuous interscalene brachial block group (CG). Patients in the SSG received 2.5 mg/kg of 0.5% bupivacaine up to 25 mL; the CG received the same dose as a loading dose via catheter followed by an infusion of 0.125% bupivacaine at 5 mL/h and a patient-controlled bolus of 5 mL hourly for 72 hours. Follow-up after discharge was with telephone calls over the next 3 days. Pain was measured on a visual analog scale. Also measured were sleep disturbance, number of opioid doses taken, adverse effects, and level of patient satisfaction. RESULTS: The median rest pain scores on the 3 days of follow-up measured on a scale of 0 to 10 (with 10 equal to greatest pain) were 0, 0, and 3 in the CG compared with 4, 4, and 3 in the SSG (P < .001) for days 1, 2, and 3, respectively. The median maximum scores were 2, 2, and 4 in the CG compared with 8, 7, and 6 in the SSG (P < .001) for the same time period. CONCLUSIONS: A 3-day continuous interscalene brachial plexus block provides better analgesia than a single-shot block. Sleep patterns were better, and less opioid was needed after arthroscopic rotator cuff repair in patients given a continuous plexus block. LEVEL OF EVIDENCE: Level I, prospective randomized study.